Healthcare Provider Details

I. General information

NPI: 1316969884
Provider Name (Legal Business Name): KANSAS CITY INTERNAL MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12140 NALL AVE SUITE 100
OVERLAND PARK KS
66209-2504
US

IV. Provider business mailing address

12140 NALL AVE SUITE 100
OVERLAND PARK KS
66209-2504
US

V. Phone/Fax

Practice location:
  • Phone: 913-451-8500
  • Fax: 913-451-1754
Mailing address:
  • Phone: 913-451-8500
  • Fax: 913-451-1754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number103093
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number111706
License Number StateMO

VIII. Authorized Official

Name: JEAN A HANSEN
Title or Position: CEO
Credential: MBA, FACMPE
Phone: 913-319-7303